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c h a p t e r 6 In the 1950s and 1960s mental health policy making was the domain of governors and their state mental health program directors. Organized psychiatry wielded great influence and was deeply involved in consequential debates about the future of mental health care in the United States. Today, by contrast, state Medicaid directors, the Social Security commissioner, the administrator of the Centers for Medicare and Medicaid Services (CMS), and human resource directors in U.S. corporations are the voices with the greatest influence on the direction of mental health policy. These policy makers have little direct connection with the specialty mental health sector. Many of their offices did not even exist in 1950. They are mainstream policy makers. The decline of mental health exceptionalism in public policy has been accompanied by a parallel decline in exceptionalism in policy making. Mental Health Policy Making at Midcentury In the 1950s mental health policy was primarily the responsibility of the states, who also paid for most care (Fein, 1958). Most of this funding was allocated to the activities of the public mental hospital, and these hospitals were managed by psychiatrists. The people most directly associated with the direction and management of mental health care were in state government, closely linked to the profession of psychiatry. In the aftermath of World War II, a sizable number of psychiatrists developed the belief that the mental hospital should no longer be the central institution of the mental health care system. This increasingly popular view of mental health delivery began to weaken the links among state government, the state hospital , and the profession of psychiatry. Organized psychiatry debated the direction of mental health delivery throughout the 1950s. Community-based psychiatry Policy Making in Mental Health Integration, Mainstreaming, and Shifting Institutions 92 Better But Not Well gained the upper hand through the leadership of psychiatrists such as Robert Rappaport, Harry Solomon, and Walter Barton. The initial reforms that began to reorient mental health care in the United States emanated from the states and from state organizations such as the Governors Conference and the Council of State Governments (Grob, 2001). Individual states such as New York, California, and Massachusetts were among the first to adopt policies that began to shift resources in the direction of community-based mental health services. These states created grant programs with incentives for the development and expansion of community-based mental health clinics, albeit with modest funding. Other states followed suit, and during the 1950s there was a dramatic expansion in the number of outpatient mental health clinics, the majority of which were funded by state government. This growth in community clinics was driven in part by a belief in community-based treatment and by the hope that such care would reduce reliance on expensive state mental hospitals. State officials and their ideas were also central to efforts aimed at identifying mental health care as a nationwide problem that had to be addressed in consistent policy terms. For example, when the Joint Commission on Mental Illness and Health (JCMIH) was created in the 1950s by a set of private interest groups and philanthropic organizations, the director of the commission was Jack Ewalt, the mental health commissioner in Massachusetts. The 1950s and early 1960s were a time when mental health became a matter for national policy. The creation of the National Institute of Mental Health in the late 1940s gave mental health policy a voice in the federal government. Technical specialists, such as the NIMH director Robert Felix, influenced the emerging federal interest in mental illness from the perspective of the specialty mental health sector. The policy statements that resulted from this initial effort of developing a national approach to mental health policy were based on ideas emerging from the professions and the states.1 The JCMIH pointed to a two-pronged strategy for improving mental health care. One prong involved improving the conditions and the treatment capacity of public mental hospitals; the other worked at developing a community-based system of care primarily aimed at people with severe mental disorders. Federal mental health policy until 1963 was limited to establishing a bully pulpit that helped activate a variety of interests to work on altering the directions of mental health care in the United States. The federal government’s expanding role in social insurance and in civil rights contributed to a view that it might work in concert with localities to fix mental health care...


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MARC Record
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